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J Thorac Cardiovasc Surg 2002;123:1041-1050
© 2002 The American Association for Thoracic Surgery
Surgery for Acquired Cardiovascular Disease (ACD) |
From the Departments of Cardiac Surgery and Anesthesiology, Istituto Policlinico San Donato, San Donato Milanese, Milan, Italy,a the Department of Critical Care Medicine, University of Florence, Florence, Italy,b and the Department of Cardiac Surgery, University of California at Los Angeles School of Medicine, Los Angeles, Calif.c
Received for publication April 5, 2001. Revisions requested May 11, 2001; revisions received Sept 25, 2001. Accepted for publication Oct 31, 2001. Address for reprints: Lorenzo Menicanti, MD, Istituto Policlinico San Donato, Via Morandi 30, San Donato Milanese, Milan, Italy (E-mail menicanti{at}libero.it).
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Abstract |
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 Top Abstract IntroductionPatients and methodsResultsDiscussionReferences |
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Introduction |
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TopAbstractIntroductionPatients and methodsResultsDiscussionReferences |
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1-4
Surgical LV restoration associated with coronary artery bypass grafting is a technique that has recently been applied to postinfarction patients with dilated ventricles and depressed systolic function (Dor procedure) and that restores LV shape and improves pump function. 5-7 Mitral repair or replacement is associated with LV reconstruction when needed; however, it is not well established which technique is most effective. 8
At our center we have adopted an innovative technique to repair moderate to severe MR during the LV restoration procedure. It consists of reducing the mitral anulus and imbricating the papillary muscles without a prosthetic ring, approaching the valve through the ventricle through the same incision necessary to perform ventricular restoration. This aggressive approach to patients with postinfarction LV remodeling and associated MR (complete coronary revascularization, LV restoration, and mitral valve repair) is aimed at surgically correcting all three negative components of the pathologic condition: ischemia, LV remodeling, and volume overload, all of which are strictly linked with one another. In this article we report the results obtained in a group of 46 consecutive patients with a previous anterior MI, severe LV dysfunction, high functional class, MR, and pulmonary hypertension who underwent combined mitral valve repair, LV reconstruction, and coronary artery bypass grafting at San Donato Hospital, Italy.
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Patients and methods |
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TopAbstractIntroductionPatients and methodsResultsDiscussionReferences |
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The mean age of these patients at surgery was 64 ± 10 years (range 38-80 years). There were 35 male and 11 female patients, and 26 patients were older than 65 years. Forty-three patients (93%) had heart failure, with New York Heart Association (NYHA) functional class III or IV.
Clinical, surgical, perioperative, and predischarge data were analyzed from patient charts, which were systematically reviewed. Follow-up information was obtained by telephone interview with the patient or referring cardiologist in March 2001.
All patients underwent preoperative and predischarge postoperative (10-14 days) echocardiographic examinations. Echocardiographic measurements were obtained with a Vingmed echocardiograph (Vingmed Holdings AS, Oslo, Norway). LV dimensions were calculated from 2-dimensional echocardiograms in standard views; LV volumes and ejection fraction (EF) were calculated by using a modification of the Simpson method with two apical views.
MR was assessed with color flow Doppler; severity was graded as mild (1), moderate (2), moderate to severe (3), or severe (4). Systolic pulmonary pressure was measured by Doppler tricuspid regurgitation velocity.
Clinical characteristics of the patients are shown in Table 1. All patients had moderate to severe MR; 55% had grade 4 MR. Ninety-four percent of patients were in NYHA functional class III or IV. In almost 40% of the cases, anterior MI was recent (<12 months previously), and in 15 cases it had occurred less than 3 months previously. The main indication for surgery was heart failure; 54% of the patients were in NYHA functional class IV. Angina alone was an indication for surgery in a few cases.
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After complete coronary revascularization had been performed, the LV was opened from the apex to the middle part, with an incision parallel to the left anterior descending artery, just over the necrotic or scarred area. The cavity was carefully inspected, and any thrombi were removed. Papillary muscles were identified, and the mitral valve was carefully checked (Figure 1). The right fibrous trigone was visualized, and a 2-0 polyester double-armed suture with a pledget was applied from the ventricular side to atrial side; the two arms of this stitch with a running suture were conducted toward the left trigone. The stitch ran a few millimeters from the mitral anulus biting atrial and ventricular muscle. The posterior anulus was completely bounded by this suture. The left trigone was reached, and the two arms of the suture were conducted from the atrial side to the ventricular side through the trigone just below the aortic valve (Figure 2). A 23-mm sizer was introduced into the mitral valve to create an undersized orifice but leave a surface area bigger than 3 cm2, and the suture was tied over a second pledget (Figure 3, A). Then the ventricular restoration was performed. The transitional zone between the healthy muscle and the infarcted zone was identified, and a 2-0 Prolene purse-string suture (Ethicon, Inc, Somerville, NJ) was applied. This encircling stitch differed slightly from the classical Fontan stitch in that it was close to the base of the papillary muscles and angulated in respect to the septum. In fact, the position and the orientation of this suture are crucial, because the orientation determine the residual shape and volume of the ventricle. The suture started from the apex of the LV and then proceeded into the middle part of interventricular septum, continuing toward the aortic valve. At a few centimeters from the aortic valve, the suture was conducted in the anterior and lateral wall, close to the bases of the papillary muscles, and then reached the LV apex (Figure 3, B). In this way the plan of the purse-string suture was as orthogonal as possible to the mitral plane, allowing a more elliptical, and thus more physiologically relevant, final shape. The purse-string suture was snared, and the bases of the two papillary muscles were imbricated, thus reducing the distance between them and also the volume of the LV cavity (Figure 3, C).
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6,7 which guides the suture closure and leaves a ventricular volume that is not restrictive. We inflated the balloon at 60 mL times the body surface area. Ventricular closure was then accomplished with or without a patch. A patch was selected if the residual neck was greater than 3 cm (Figure 4); direct suture was performed if the neck was smaller. The technique allows a reduction of both longitudinal and transverse dimensions, thus keeping LV volume and shape near normal (Figure 5).
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2 test, and relative risk analysis tests were used as appropriate. Variables that resulted in significance in the univariate analysis were tested in a multivariate logistic regression analysis to assess predictors of mortality. |
Results |
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). Overall, EF did not change significantly. Twenty-six patients had a significant increase in EF, whereas 4 had no changes and 9 showed a slight reduction. Pulmonary artery pressure and end-diastolic diameter both decreased significantly.
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Discussion |
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Anatomic and functional ventricular alterations and mechanisms of functional mitral regurgitation in ischemic cardiomyopathy
A large anteroseptal transmural MI determines a dilatation of the LV with elongation of the longitudinal and transverse diameters; this causes an abnormal orientation of the papillary muscles, with lateral displacement and increased forces toward the apex. The increase of the transverse diameter also leads to a widening of the two papillary muscles. In the normal heart, the transverse diameter is almost half the longitudinal one; when the heart dilates after an MI, the sphericity index (the ratio between the two diameters) approaches 1.
When the shape of the ventricle approximates a sphere, the lateral wall tension increases and the fiber shortening is reduced. The papillary muscles are shifted and the posterior leaflet is pulled down, determining an increase of the tenting area and a decrease of leaflet coaptation (local remodeling). 3
Functional MR therefore is seen in patients with normal mitral apparatus and frequently complicates ischemic cardiomyopathy. Its presence causes pulmonary hypertension and volume overload, which in turn potentiate LV dilatation. Annular dilatation, ventricular dilatation (global remodeling), and local remodeling are all factors that interplay in determining MR. 3,9
Mitral valve surgery
Mitral valve surgery in ischemic and nonischemic cardiomyopathy potentially has the greatest benefits for patients with severely depressed pump function, but correction has not been routinely undertaken because of the presumed high operative mortality. This has made the management of such cases problematic and controversial; however, more recently some authors, 10-13 and in particular Bolling and coworkers, 14,15 have reported an improvement in symptomatic status and survival among patients with end-stage cardiomyopathy and severe MR, thus emphasizing mitral repair in end-stage cardiomyopathy as a new and effective strategy for these patients. Several different technique for reducing the mitral anulus have been reported since 1957, when Lillehei and coworkers 16 reported the first procedure of anulus reduction. In ischemic MR, the results are more favorable to the mitral plasty with reduction of the posterior anulus without a prosthetic ring. 13 Carpentier 17 in 1969 introduced the concept of mitral ring replacement and completely changed the surgical approach to mitral valve. More recently, the idea that a rigid ring can interfere with the outflow tract determining gradients was introduced, and some concern arose about a decreased performance of the LV. At present there is not conclusive evidence in the literature in favor or against a rigid ring, because a flexible ring can have only a marginal advantage in extreme situations. 18,19 In more recent literature there has been a new interest in different mitral valve repair techniques that avoid a prosthetic ring. 20
In our patient population the reduction of the anulus is achieved without a prosthetic ring with a technique similar to that described by Shore, Wong, and Paneth, 21 with the difference that we approach the valve through the LV, through the incision necessary to perform ventricular restoration. When the ventricle is enlarged the mitral valve can be exposed well from the ventricular cavity, and the two trigones are identified more easily than through the atrium. The mitral valve in these patients is absolutely normal; there are no signs of degenerative disease, and the fibrotic tissue of the trigones is strong enough to bear the tension of the annular stitch. Ventricular restoration with imbrication of the papillary muscles and reduction of ventricular volume further reduces the tension, stabilizing the shortening of the posterior anulus.
Surgical left ventricular reconstruction
Dor and coworkers 5,6,8 have extensively reported clinical and hemodynamic results of endoventricular circular patch plasty repair of the LV for postinfarction akinetic and dyskinetic scar. The technique, the Dor procedure, aims at restoration of LV geometry and fiber orientation and therefore represents an effort to attenuate negative LV remodeling in an attempt to improve survival and quality of life. 5,6,8 The technique has an acceptable operative mortality rate (<10%), even for patients with preoperative LV dysfunction. Reported data show an improvement in global EF, a marked reduction of volumes, and a decrease of NYHA functional class, as well as an improvement in LV shape and geometry. The improvement in global pump function is due mainly to the increase in regional wall motion remote from the anterior scarred wall. 22 Moreover, the procedure improves late survival (82% at 5 years), which is highly influenced by preoperative end-systolic volume index and clinical status. 23
Overall, there was no significant change in EF after surgery in our current series with MR. The lack of increase in EF is in contrast with the significant increase obtained by Bolling and colleagues 14,15 in dilated nonischemic cardiomyopathy. However, our patients are different from those reported on by Bolling and colleagues 14,15 in that they all had an anterior MI. It is difficult to characterize ventricular function in the setting of MR because of the reduction in afterload caused by mitral incompetence. Thus EF, like any other measure of systolic function, tends to overestimate the degree of function, and it is likely that in our patients the true degree of preoperative function was lower than was estimated by EF. In some studies EF has been reported to decrease after mitral surgery despite an improvement in end-systolic volume and a reduction of stress-volume ratio. 24
In conclusion, our population with Q-wave LV anterior MI, marked ventricular dilatation, high grade of MR, pulmonary hypertension, high functional class, and severely depressed ventricular function had a poor prognosis, with extremely high risks for death and subsequent cardiac events. The aggressive combined surgical approach with LV reconstruction, complete coronary revascularization, and mitral valve repair tended to correct the three components of the disease by reducing LV tension, relieving ischemia, and reducing volume overload. Although a longer follow-up is mandatory, we believe that the innovative transventricular procedure for mitral repair without mitral prosthetic ring requirement is highly effective in relieving MR. It allows ventricular and mitral repair from the same approach and is therefore shorter. In our experience the trigones are better identified from the ventricular than from the atrial approach, and the posterior anulus potentiates the reduction of the transverse diameter obtained by volume reduction (by approaching the two papillary muscles) and thus contributes to a more physiologic correction of the LV shape, consequently leading to a better function.
We suspect that both the annular and the ventricular sutures are geometrically effective in reducing MR, especially when the encircling ventricular suture is correctly angulated in respect to the septum. The mitral anulus repair is perhaps the first mechanism that relieves volume overload, but the improved LV geometry is essential to maintain the efficacy of the repair.
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L. Menicanti and M. Di Donato The Dor procedure: What has changed after fifteen years of clinical practice? J. Thorac. Cardiovasc. Surg., November 1, 2002; 124(5): 886 - 890. [Full Text] [PDF]
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